Posted: May 31, 2017

Comparison of Clinical Decision Support Tools in Venous Thromboembolism in a Rural and Urban-Cluster Hospital

Description

VTE risk stratification has been well studied and validated to act as a guideline for patients who present with suspicion for PE. This study looks at how patients are managed after they present to the ED at a rural and university hospital with clinical suspicion for PE. Background: Evidence-based protocols, such as Wells Criteria and Pulmonary Embolism Rule-Out Criteria (PERC), act as a guide for D-dimer assays to minimize patient exposure to imaging studies while maximizing the detection of patients with pulmonary embolism (PE). Adherence to these protocols has demonstrated a cost-effective means to risk stratify patient care. Non-adherence can result in unnecessary imaging and inappropriate ordering of D-dimer where the test is not useful. This study looks at compliance of these protocols in a rural and university-based community hospital emergency department (ED). Implementation: A retrospective review of ED patients who received D-dimer test at rural Pleasant Valley Hospital (PVH) and Marshall University Cabell Huntington Community Hospital (CHH) from 2014 to 2016 was performed. Patients who presented with lower extremity only complaints were excluded. Data points specific to Wells Criteria and PERC were obtained. Patients were classified into low, intermediate and high risk based on Wells Criteria. Low risk group were divided further into PERC positive and negative groups. Patient managements were recorded to determine if they followed protocol. Evaluation & Outcomes: Of the 610 patients at PVH, 380 (62%) followed protocol (CI, 95% 0.58-0.66) and 230 (38%) did not, with a PE incidence of 13 (2%). Of those patients, 513 (84%) had appropriate D-dimer testing (CI, 95% 0.81-0.87). Of the 610 patients at CHH, 312 (51%) followed protocol (CI, 95% 0.47-0.55) and 298 (49%) did not, with a PE incidence of 2 (0.3%). Of those patients, 371 (61%) had appropriate D-dimer testing (CI, 95% 0.57-0.65). CTPA were also over utilized. At PVH and CHH respectively, 31% and 39% of CTPA could have been avoided. Impact & Lessons Learned: Inappropriate use of D-dimer tests in the rural and university hospital is observed. Adherence to protocols is currently suboptimal resulting in increased exposure of patients to radiation and contrast as well as increasing the cost of care. By applying protocol-based evaluation for PE we may be able to reduce cost of care and unnecessary testing in a rural setting, while improving compliance and patient care.

Keywords

Evaluation, Cost, Pulmonary, Improving, Care, Reducing, Embolism

Authors

Haris Kalatoudis, MD, Marshall University School of Medicine

Emily Kalatoudis, MD, Marshall University School of Medicine

Fuad Zeid, MD, Marshall University School of Medicine


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